All posts by TheTraumaPro

What INR is Safe for Ventriculostomy Placement?

Intracranial pressure monitoring has been shown to benefit patients with severe brain injuries. Neurosurgeons are reluctant to place these invasive monitors in patients with abnormal coagulation studies, and many times expect the coags to be completely normal. Is this reasonable? Brain injury itself can raise the INR. When is it safe to place one of these monitors?

Researchers at the University of Alabama – Birmingham performed a retrospective review of their experience with 71 patients who underwent ventriculostomy with a range of INR values. None of these patients were on warfarin. Eighty one ventriculostomies were performed after an average of 1.5 attempts. They looked at the incidence of new hemorrhage seen on CT after placement. They found:

  • Patients with an INR < 1.2 had a 9% incidence
  • Patients with an INR from 1.2 to 1.4 had a 4 % incidence
  • Patients with an INR > 1.4 had an 8% incidence

If the neurosurgeon, is unwilling to place the ventriculostomy until the INR is normalized, there may be several additional sources of morbidity:

  • Additional brain injury that is not known and treated due to the lack of an ICP monitor
  • Potential infectious and other complications (transfusion reaction, TRALI) from plasma administration
  • Cost for the transfusion products

The patients who did have hemorrhage generally had a small focal area. The one significant hemorrhage occurred in a patient on clopidogrel (Plavix). 

Bottom line: The numbers are small, and this is retrospective work. Based on their study, the authors are comfortable placing ventriculostomies in patients not on Coumadin with an INR up to 1.6 without plasma administration beforehand. Colpidogrel should be considered as a separate risk factor.

Reference: The relationship between INR and development of hemorrhage with placement of ventriculostomy. Bauer DF et al. J Trauma, in Press Aug 27, 2010.

New Technique for Fasciotomy Closure

Fasciotomies are much more easily opened than closed! Once the edematous muscle is released, it’s not easy to get the skin to close over it again. On occasion, an immediate closure can be carried out. But in most cases, the process is performed with one or more additional operations.

Continuous tension across the skin edges is important. This keeps the wound from getting wider while the edema decreases. A number of creative techniques have been employed to keep the wound from widening, including using sutures, vessel loops, and fancy (expensive) plastic fasteners. And although the KCI VAC dressing reduces edema, it does not do much to pull the wound edges together.

Surgeons in the Netherlands came up with a novel technique using a cheap device that can be found in any hardware store and gas sterilized. The Ty-Rap closure device is commonly used to secure chest tubes to their connectors. Bigger versions are used by police in lieu of handcuffs.

The tail of one Ty-Rap is cut off and the hub is placed on the tail end of another. This assembly is placed across the wound, and one staple is placed over it on each side of the wound. This process is repeated for the entire length of the wound (picture). The Ty-Raps are tightened, and then slowly retightened daily until the wound comes together. An additional week to 10 days is allowed for wound healing before removal of the Ty-Raps.

The authors used this technique on 23 extremity fasciotomy wounds. The wounds were closed after an average of 6 days, and the TyRaps were removed after 16 days. There was no skin necrosis, but there were two instances of cellulitis. The cost of the materials (TyRaps and a surgical stapler) was $23, excluding assembly and sterilization.

Bottom line: This is an interesting technique with good closure results. The surgeon does have to plan ahead and get hospital clearance to use these devices, though.

Reference: Ty-Raps in trauma:  a novel closing technique of extremity fasciotomy wounds. J Trauma 69:972-975, 2010.

TyRap closure

Emergency Medicine & Trauma Update – Bloomington, MN 10/28/10

“Torso Trauma Update” presented at 8:40AM.

For a copy of the slideset, click here.

Bibliography:

  • What is the utility of focused assessment with sonography in trauma (FAST) exam in penetrating torso trauma? Injury, in press, 2010.
  • CT of blunt abdominal and pelvic vascular injury. Emerg Radiology 17:21-29, 2010
  • More operations, more deaths? Relationship between operative intervention and risk-adjusted mortality at trauma centers. J Trauma 69(1):70-77, 2010

Can Texting Bans Be Bad?

By now, everyone probably knows that texting while driving is bad. So legally banning texting is good, right? It seems that way, since everyone is doing it. Thirty states plus the District of Columbia currently ban texting while driving, and a third of those laws were passed just this year.

Talk about the law of unintended consequences. The Highway Loss Data Institute compared collision insurance claims before and after bans were put into effect in four states (CA, LA, MN, WA). Crash rates actually rose in three of the four states after the bans were passed.

How can this be? Unfortunately, the claim data can’t tell us what the increase is due to. They speculate that texting drivers are trying harder to conceal their habit, keeping their phones out of sight and taking their eyes off the road even more. Or, it could just be a statistical fluke.

The federal Transportation Secretary disagrees. He stated that distracted driving fatalities increased from 2005 to 2008, but stopped rising in 2009. I’m not clear on where this data comes from.

In either case, texting remains a bad thing to do. This debate just points out that bans are not the complete answer. Prevention programs and behavior modification need to be developed to comprehensively address this problem.